2024-2025 Emergency Medical Treatment Authorization and Student Insurance Statement

Emergency Medical Treatment Authorization and Student Insurance Statement

2024-2025
This form must be completed annually for each student, prior to the first day of school. Please complete this entire form, sign and submit.
Student's Name:*

First NameLast Name
2024-2025 Grade:*
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
As the legal parent or guardian of the above named student, and in the event of an injury or illness which requires immediate examination or treatment, in the opinion of University Lake School officials, I authorize University Lake School on my behalf to have my child transported by car or ambulance to the nearest hospital. Necessary emergency treatment may be given by any doctor on call.

The parents of a student who incurs an injury or suffers an illness that requires more than first aid will be notified as soon as practical after the injury occurs. In an emergency, this notification may occur after the student has been transported to and/or treated by a doctor, clinic or hospital.

I understand that the school assumes no financial responsibility for medical care or ambulance conveyance. We further understand that ULS does not carry medical expense insurance for the benefit of any student who may be injured while participating in school activities and that ULS assumes no responsibility for such medical expense. We further understand that a student who does not have health insurance coverage will not be permitted to participate in athletics unless this statement is signed and filed with the Head of University Lake School. We consent to having our son/daughter participate under these conditions and authorize the treatment of injuries and illness incurred by our child in accordance with the procedure described above.
Emergency Contacts
Please fill in the contact information for the two parents or other primary guardians/caregivers to be contacted first in an emergency.
Parent or guardian - first person to contact in case of emergency:*

First NameLast Name
Relationship
Cell Phone Number*

Area CodePhone Number
Home Phone Number

Area CodePhone Number
Work Phone Number

Area CodePhone Number
Parent or guardian - second person to contact in case of emergency:*

First NameLast Name
Relationship
Cell Phone Number*

Area CodePhone Number
Home Phone Number

Area CodePhone Number
Work Phone Number

Area CodePhone Number
Additional Emergency Contacts:

Person(s) to call if parent(s) or guardian(s) cannot be reached in an emergency.
Contact 1:

First NameLast Name
Phone Number

Area CodePhone Number
Relationship
Contact 2:

First NameLast Name
Phone Number

Area CodePhone Number
Relationship
Authorized Pick-Ups
List the full names of anyone authorized to pick up your child(ren). Anyone not listed below requesting to pick up your child(ren) will have to be authorized via phone by a parent.
Name*

First NameLast Name
Relationship
Name*

First NameLast Name
Relationship
Name

First NameLast Name
Relationship
Insurance Information
Insurance Company*
Group Number*
Policy Number*
Please list all dietary restrictions:
Medications
If your child must take prescription drugs on a continuing basis, or if your child has any allergies or health concerns our staff should be aware of, please name the drugs and describe the medical condition.
Prescription Medication
Dosage
Prescription Medication
Dosage
Please list any medical conditions:
Please list all of your child's allergies:
Checkmark medications you approve for dispensing.*

Regular TylenolExtra Strength TylenolJunior TylenolChildren's TylenolIbuprofenChildren's IbuprofenBenadrylTums/RolaidsOther
Preferred Medication Dosages (if different than product dosage recommendations)
The information provided here is accurate. I give University Lake School Permission to treat my child.*

Clear
Parent or Guardian's Signature Required.
Parent/Guardian Name*

First NameLast Name
Date*

MonthDayYear
Date
Email Address to Receive Confirmation:
example@example.com
Should be Empty:

Emergency Medical Treatment Authorization and Student Insurance Statement

Emergency Contacts

Additional Emergency Contacts:

Authorized Pick-Ups

Insurance Information

Medications